They Deserve Better

Advocates call for long-term solutions to address the crisis in residential care

There is little question that BC's long-term care sector was in desperate need of attention long before the COVID-19 pandemic struck.

Beyond the unending staffing shortages that already existed, care providers were regularly managing unsustainable workloads in overcrowded facilities in need of repair, while caring for residents with a wide variety of acute needs, including dementia, mental health issues, substance use disorders and psychiatric illness.

Over the years, calls for help have come from those working in the system, from family members with loved ones living in care facilities and from numerous health-care advocates, including the BC Nurses' Union, demanding that both provincial and federal governments take immediate action to help a residential care sector in serious need of repair.

BCNU is one of many organizations demanding that policy makers and governments take action to address multiple challenges in this province's long-term care sector. But it has been an uphill battle.

Long-term care, along with assisted living and home health care are critical parts of BC's public health-care system. Yet BC seniors today have less access to these services than they did in 2001. Almost 20 years of underfunding, privatization and fragmentation of the system have left many seniors, their families and communities patching together care – and even going without.

Between 2001 and 2016, access to long-term care and assisted living spaces declined by 20 percent (measured as beds relative to the population of people 75 and over).

Staffing levels at these care facilities have also been dangerously low, and the government's quick fixes and Band-Aid solutions have not provided long-term relief for health-care workers. What's worse, all of this has had a direct, negative impact on quality patient care.

In the absence of an effective long-term care sector health human resource plan, and with the added new stressors of a pandemic, it is little wonder that the health and safety of the sector's chronically short-staffed workforce has been impacted.

The crisis has also affected the special bond that staff have with the residents in their care.

Unfortunately, years of negligence and the government's unwillingness to maintain and strengthen seniors' care meant that BC's long-term care sector was no match for the first wave of the COVID-19 pandemic that took hold last spring, and the far more devastating second wave that came in the fall.

COVID-19 in BC's Long-term Care Sector

On March 7, 2020, BC's Provincial Health Officer, Dr. Bonnie Henry, told reporters that two residents and one health-care worker at North Vancouver's Lynn Valley Care Centre had tested positive for COVID-19. The next day, one of the residents would die, becoming the first person in Canada to succumb to the virus.

Since that dreaded week, the COVID-19 death toll in seniors' residences has been hard to comprehend and the pandemic has proved to be deadlier in provinces that failed to learn from the first wave and prepare for a resurgence of the virus. BC is one of those provinces, where last fall's second wave saw 567 resident deaths compared to 120 resident deaths the previous spring, a more than four-fold increase. In total, 392 care homes in BC have been affected by COVID-19, with the province reporting a 29 percent resident fatality rate.

BCNU executive councillor for seniors Michelle Sordal says that as infection numbers climbed, it quickly became obvious that nurses and those working in the facilities didn't have access to appropriate personal protective equipment, and there were numerous reports of communication breakdowns about outbreaks and concerns that infection control protocols were routinely being missed.

"The pandemic has had devastating consequences for both residents and staff in the long-term care sector."

- BCNU Executive Councillor Michelle Sordal

"We had members send us photos of themselves in painting gowns and masks because that was all they could get their hands on," she reports. "Nurses were going out and purchasing what they could find as there was very little effort on the part of their employers to ensure they would be kept safe."

To make matters worse, COVID-19 outbreaks on floors where residents live with dementia proved almost impossible to contain. Nurses were then getting sick themselves, which meant fewer staff were available to work.

BCNU was among many health-sector unions and organizations that assisted in helping to implement the provincial health office's single site order last April. It restricted the movement of workers employed in long-term care, assisted living and private mental health facilities. The union also ran a province-wide occupational health and safety campaign to educate members on the importance of practising the precautionary principle when caring for residents in the pandemic.

Major Reforms are Needed

The COVID crisis has brought the long-standing problems with seniors' care into stark relief.

BCNU is one of a number of health-based organizations that has endorsed several recommendations in a new report by Action for Reform of Residential Care (ARRC), a non-partisan voluntary citizens group.

One of these recommendations is the call for a "person-centred care model" that consists of a stable, well-trained and well-supported work force, including on-site RN leadership and organization of work.

"It's time that we get registered nurses back into long-term care facilities and onto health teams in order to provide a well-rounded, adequate amount of patient care that is needed," says Sordal. "What we have seen is a drastic reduction in the number of RNs in the long-term care setting, which has led to a lack of support for both the health teams on the ground, and negative outcomes for patients."

Sordal also points to the risks associated with for-profit ownership and financialized corporate chains, and the large body of research showing how staffing levels and the care provided in for-profit long-term care facilities is generally inferior to that provided by public and non-profit-owned facilities. High staff turnover, which is linked to lower wages and the heavy workloads demanded by inadequate staffing levels, is associated with lower-quality care in large for-profit facilities.

The BC government's longstanding practice of relying on private finance capital to build new facilities means that corporate chains now control over one-third of all publicly subsidized and private-pay long-term care and assisted living spaces in BC, while two-thirds of units are owned by either non-profit agencies or health authorities.

"As outlined in the BC Seniors' Advocate's report, A Billion Reasons to Care, for-profit care homes failed to deliver 207,000 funded direct care hours in fiscal year 2017–18, even while receiving the same level of public funding," says Sordal, noting that for-profit homes spend $10,000 (24 percent) less per year than for-profits on direct care for each resident.

She says the deadly coronavirus pandemic that has swept through nursing homes across BC and Canada has made it clear that for-profit facilities aren't delivering a safe level of care to their vulnerable residents.

BCNU's Work Ahead

It is vitally important to recognize the important contribution that long-term care nurses are making to the province's health-care system. And calling for improvements to the long-term care sector is a top priority for BCNU – especially as COVID-19 continues to put pressure on staff, increase workload and expose gaps in patient care.

The union's seniors' strategy working group, which consists of elected members and researchers, continues to meet monthly to discuss priorities in long-term care and how the union can best support the nurses working in the sector, all of whom remain committed to providing the best patient care despite the harrowing year that's passed, and the uncertainty the future brings.

When the pandemic has passed, BCNU expects that the government will conduct a comprehensive review of BC's long-term care system and do more to improve working conditions for long-term care nurses and providers – all in the name of patient care.

Sordal says there is no question that nurses should have a seat at the table once that review begins.

"Years of budget cuts, shrinking resources and a lack of attention to a chronically short-staffed workforce have collided with the unprecedented demands of the pandemic, and that has had devastating consequences for both residents and staff in the long-term care sector," she says.

"The coronavirus has shown us that we don't have time to waste – the system is broken and we must do all we can to fix it, so that it's strong enough to meet the needs of all residents now and in the future."

It's Time for Better Long-Term Care Staffing

The COVID-19 pandemic's devasting impact on the long-term care sector has led to renewed calls for legislated nurse staffing requirements to ensure that staff and the residents in their care can safely live and work with dignity.

BCNU has endorsed the recommendations contained in Improving Quality of Life in Long Term Care – A Way Forward, a new report by the advocacy group Action for Reform of Residential Care (ARRC).

The report's call for a "person-centred care model" is based on the recognition that a stable, well-trained and well-supported work force, including on-site RN leadership and organization of work, is critical for the provision of quality care.

But this vision cannot be realized until governments make critical investments in nurse staffing. Unfortunately, over a 10-year period, the number of RNs working in BC's long-term care facilities has dropped significantly compared with numbers of LPNs.

Currently, BC has no legislation governing the staffing of long-term facilities, whether that be minimum numbers of staff or the type of staff providing care.  Indeed, in BC, unlike most other provinces, there is no requirement that long-term care facilities have an RN on duty 24/7.

The provincial government's residential care staffing guidelines recommend that each resident receive 3.36 worked hours of direct care per day, and no less than 20 – 25 percent of those hours should be professional care (i.e., provided by RNs and LPNs).

Studies that have explored the relationship between resident care and RN staffing have found that higher levels of RNs result in fewer trips to the emergency room and achieve positive health outcomes overall. The health teams, consisting of LPNs and care aides, also benefit from having more RNs present, as this allows nurses to perform within their scope of practice. It also provides for the critical and often "hidden labour" of the nurse's job, which is the emotional component that is such a large part of a long-term care nurse's role – a role that has evolved from caregiver, to "family member" as so many relatives of residents have been denied visiting rights due to the risk of bringing the virus into care facilities.

"The government must take into account our calls for onsite RN leadership in long-term care facilities," says BCNU executive councillor for seniors Michelle Sordal. "Over the years, we've seen the reduction of staffing resources and limited access to quality of life supports. The system was not strong enough to adapt to this pandemic, and we've seen the devastating consequences that have resulted from it. We must all work hard to make the system stronger than it was before."

BCNU supports the ARRC report recommendation that the Ministry of Health set a standard of actual direct care nursing hours worked per resident per day at 4.1 hours, and that facilities be funded and monitored effectively to ensure they meet this standard.

BCNU is also calling on the government to develop a clear definition of direct care hours. •

UPDATE (Spring 2021)